This is my column in EM News for the month of January. Sometimes, being a physician means saying no and being disliked. It’s not a popularity contest! It’s about doing the right thing.

Most of us went into medicine because, in addition to being good students, we wanted to help people. How many oceans of ink and forests of paper have been used explaining that point to admissions committees we’ll never know. Suffice it to say, it felt very good when our professors wrote us glowing letters of recommendation. Of course, we were also saying, “I want to feel good about helping people. I want the recognition associated with the act of helping!” Premedical students, medical students, and physicians tend to be those people who desire accolades and who are naturally well-suited to attaining them.

It is deeply moving to hear patients say, “You saved my life.” Or for a parent to say, “My child is alive because you were there.” Those words light up the pleasure centers in our overachieving brains.

It was, therefore, painful for me to finally realize that people sometimes disliked me. In fact, sometimes they despised me! This is the great unspoken reality of the practice of medicine. We won’t always be liked. If you doubt it, walk around Walmart for a few days. Some of your former patients will hug you. Some will snarl at you. That’s life as a medical doctor.

It’s all too easy to suggest that patients won’t like us because we make mistakes. That’s a given but not necessarily the biggest contributor to our being disliked. No one likes when their doctor, or their mechanic, for that matter, makes a mistake. I remember the dentist who gave me a root canal on the wrong tooth. I was a little unhappy, but he had been the family dentist for years so I didn’t really have animosity toward him. I just had a bill and a hole in my tooth. (And not so much as a whiff of nitrous oxide!)

Anyone who analyzes malpractice will report that a physician can make a mistake, sometimes a pretty big one, and patients (and their families) will still forgive them. It’s mostly in the attitude you show toward them, the concern you display, the connection you establish.

Being disliked is not just about mistakes. Being disliked is about humanity and expectations. Humans often expect and desire things they shouldn’t have. Is that judgmental? I hope so. I went to school for a very long time to learn to make judgments and take responsibility for them. Should I be the arbiter of human desires? Maybe not, but as things stand, I have to be.

Here’s the reality. People frequently come to the emergency department because they want pain medication. Human beings have pain, addictions, and an occasional tendency to break the law by selling their medications. Because our government limits access to narcotics, I have to stand in the middle and make decisions about who does or does not receive them. This makes things ugly at times. I won’t be liked when I say no. I don’t even like saying no. I don’t like believing someone might lie to me. But one of my partners recently wrote a prescription for narcotics, and within an hour, the patient was caught, standing outside a pharmacy trying to sell his pills. To avoid that sort of possibility, I have to say no.

I have to say no when someone wants any drug or test that won’t work or may be bad for them. Occasionally I have to say no to CT scans, x-rays, and antibiotics. I try my best to explain my rationale. Usually it works. Sometimes it doesn’t. And bingo! I’m disliked. “Well, I just think I need some x-rays or blood tests.” I understand and respectfully disagree.

I even say no to school and work excuses. Frankly, that bruise shouldn’t limit anyone’s ability to check out groceries. And though my neuroanatomy might be a little rusty, I’m confident that teenaged student’s ankle sprain isn’t directly connected to his frontal lobes, and should not impair learning.

I think in the end saying “no” when “yes” is desired is what makes patient and families dislike us more than anything else we do.

The problem, however, is larger. We live in a culture of yes. We live in a culture of spoiled children of all ages who think that the only answer to any question is a resounding “yes.” Yes to admissions for convenience. Yes to endless care at no cost. Yes to validating non-diseases. The ridiculous parenting attitudes of the past 30 to 40 years translated into a society of adults who throw tantrums when they don’t get what they want, medically, personally, economically, or politically. And once they grow out of stomping their feet and holding their breath, they move on, and fill out angry satisfaction surveys or write scathing evaluations of their doctors or anyone who denies them, in anonymous online forums.

Administrators and academics, also educated and nurtured in the same country at the same time, also eager (as all of us are) to please, make policies that echo this hellish false-construct. If someone is unhappy because they were told no, then the person who told them no is at fault, is cruel, is judgmental, or intolerant, and should be reprimanded, punished, re-educated, or fired.

In our culturally misguided desire to please everyone, we wreck medicine, ruin the lives of patients, and seriously endanger our country with too many narcotics, too many drugs and tests, too many people on disability, and too many doctors (and politicians) struggling to avoid that most terrible of all accusations: “He didn’t give me what I wanted!”

The hard, liberating truth is this: Good doctors do the right thing. In the process, they may make patients unhappy. But if being liked and producing satisfaction on paper is the end-game for this great adventure of medicine, then we are seriously off course, and we can simply throw out all research and focus on the science of pleasure. Medicine can become one great big house of ill repute.

Ironically, if we think there is bias in corporate research or bias in our interactions with pharmaceutical representatives, we should open our eyes to the terrible cultural bias that expects us to answer every request with “yes.” That bias thinks good doctors are never disliked when it may well be that, contrary to popular thought, the best and the brightest are sometimes disliked and are still willing to say “no.”

34 Comments

This is true in all professions. I work at a laundromat and most people at my job do think I’m sweet, kind, friendly, etc.

But I am always a bit amused by the number of people who think freebies are theirs for the asking, no matter how many times they are told ‘No’, who think that rules against sitting on the tables/in the laundry carts don’t apply to them. These people think I’m a rude, mean, #^%$*#^$-type person.

I can live with that. I take it as a sign that I still have good boundaries.

As medical director for a medium sized ED in Western Kentucky, I was just finishing up my post holiday complaints this morning. There was a particularly irritating complaint from a woman who felt it necessary to complain to my administration because one of my physicians ordered a urine pregnancy and would not comply with her demand for a serum test instead. Just picked up your article, wish I could have attached this to the complaint and sent it in as my comments. I may reference this article in the future, it was a little more eloquent than my comment, the customer is not always right….

Edwin, Now that made me smile. Right on! (not to be confused with me smiling because I think you should be a comedian, although you do have a great sense of humour.

I agree with other posts that this applies to all jobs/lives. Anytime we “manage/care for/teach/guide” others they will/may dislike us. It applies to child-rearing. Children often “dis-like” their parents when they say “no”. Doing these jobs require love for the being on the receiving end, for they often are not able to properly care for themselves. It is then our jobs to say “no”, but with love, patience and guidance because we care. I often have thought of certain jobs that would cease to exist if it were not for the very reason for their existance. Exterminators need parasites, varmits, fleas, etc. Lawyers need criminals and small minded folks. Teachers need the uneducated, ignorant, etc. Doctors need the diseased and negligent. My point is the undesirables make for job security. I accept them as part of the life cycle.

Finally, thank you for being the type of doctor who has the nerve to take on the war against over-prescribed drugs. I applaud you for that. Also, be thankful your novocaine or lydocaine? worked on a root canal. It doesn’t always work well for me and I recently was given nitrous oxide because of it during a wisdom tooth extraction. YES, I did feel it but thankfully I didn’t care too much. Better than my DDS wanting to put me under. There is a time and a place to live through chemistry.

What about Dennis Sandlin? He is the Kentucky physician shot to death last month while in his clinic. He had refused to give a narcotic script to a patient. So much for saying no. After 23 years of emergency medicine, I am not very inclined to say no very often. Not only does it result in poor patient satisfaction scores and the possible job loss accompanied by low scores, but increasingly we are not safe saying no. I am tired of being threatened by patients who don’t get the controlled substances that they desire. We see an unstable, unpredictable population of psychiatric and substance abusing patients. At this time in my career, I need to feel safe walking the halls of the er, walking out the door after work and going home. I can’t change society, hospital administrators, patient satisfaction scores or pain scores. But I can feel safer by not saying no as much.

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